Medication Error from Failure to Verify Resident Identity Before Opioid Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing services and medication administration were provided in accordance with professional standards of practice and facility policy, specifically the verification of resident identity prior to administering medications. Facility policy on “Medication Administration” required licensed nurses to verify resident identity, including use of the resident’s photograph in the MAR, and to administer medications as ordered and in line with professional standards. State nursing standards cited in the report required RNs to exercise sound nursing judgment, administer drugs as ordered, and follow accepted codes of behavior to assure safe and effective practice, including adherence to the 5 Rights of Medication Administration. Resident 50 and Resident 51 were cognitively impaired roommates, each with severe cognitive impairment as evidenced by low BIMS scores on recent MDS assessments. Resident 50 had physician orders for morphine sulfate oral concentrate 20 mg/ml, 0.5 ml by mouth once daily, and levothyroxine sodium 25 mcg by mouth daily. Resident 51 had diagnoses including dementia with severe cognitive impairment. On the morning of the incident, an agency RN (Employee 1) entered the shared room, called out Resident 50’s name, and Resident 51 responded. The RN then approached Resident 51, identified the medications prepared for administration (morphine sulfate 0.5 ml and levothyroxine 25 mcg), received an “okay” response from Resident 51, and administered Resident 50’s medications to Resident 51. After leaving the room and returning to the computer to document, the RN realized the medications had been given to the wrong resident. The RN obtained Resident 51’s vital signs, which showed low blood pressure and bradycardia, and emergency services were contacted. Hospital records documented that Resident 51 arrived with abnormal vital signs, including a heart rate of 29 beats per minute and low blood pressure, was alert but disoriented, and was treated with two doses of naloxone for opioid poisoning and profound bradycardia. The resident was diagnosed with accidental opioid poisoning. In a subsequent interview, the RN acknowledged administering medication to the wrong resident and confirmed that she did not follow accepted medication administration practices or the 5 Rights of Medication Administration, leading to the resident receiving another resident’s opioid medication and experiencing adverse clinical effects requiring emergency medical treatment.
Plan Of Correction
1. Facility cannot retroactively correct deficiency as it relates to resident 51 on 4/6/2026 and a medication error. 2. Audited medication errors from 1/1/2026 to current to review root cause of errors. Results have been added to our education component for licensed nurses. 3. As outlined by the self-directed letter, AAE Consulting Services, approved by the Department of Health, will provide facility-wide education on the program called "Professional Standards and Significant medication error standards as well as federal regulations and accompanying guidelines. Education will be provided by AAE Consulting Services to conduct the directed in-service sessions on 4/23/26. Anyone that is unable to attend the 4/23/26 sessions will be required to be completed prior to their next scheduled working shift. A copy of the in-service will also be added to agency orientation documents for review prior to working a shift within the facility. All residents who did not refuse have been issued wrist bands for a secondary identification. Wrist band checks added to residents' TAR per shift to check for placement. All resident pictures for primary identification have been uploaded in their respective EMR's on 4/9/2026. 4. Facility education will be completed biannually with licensed nursing staff for the 5 rights of medication verification. Education will be included in all new licensed nursing staff education during the initial orientation process upon hire. Educations will be audited monthly by the DON/designee and forwarded to the QA committee to ensure compliance with resident identification during medication passes. 5. April 25, 2025
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